It is very good to see Changing Faces nominated as the BMA charity of the year, both because it is an outstanding organisation and because the nomination recognises a reality of which too many people are unaware.

I know Changing Faces well. Run by its founder, the indefatigable James Partridge, it supports and represents people with disfigurements to the face, hand or body. It is imaginative, innovative, collaborative, and a model of good governance.

Given the financial belt-tightening that affects almost everyone at present, it is hardly surprising that there has been a marked reduction in donations to charities. The report, UK Giving 2008, published jointly by the Charities Aid Foundation and the National Council for Voluntary Organisations says that cash donations to charity fell from £1.7 billion in 2006/07 to £1.3 billion in 2007/08, and that was before the recession had really begun to bite. Anecdotal evidence suggests that donations by the public and businesses have decreased sharply since the report was written. This should particularly concern those involved in the care of people with long term conditions.

The realities of charitable fundraising are not well understood by many people. Essentially, health charities and patient support groups seek funding from a range of sources, including membership subscriptions, charitable trusts, business and public donations, retailing (charity shops, Christmas cards and the like), fundraising events, legacies, investment income and government grants. The proportions that each of these contribute to charities’ incomes is very variable and to a disconcerting extent, emotionally driven.

Charities for frightening, potentially fatal conditions such as cancer, heart disease, Alzheimer’s’ disease, Parkinson’s disease and stroke illness, attract high levels of funding. And success breeds success. Their fundraising departments are well resourced, professionally staffed and highly effective. Additionally, because such illnesses tend to come towards the end of people’s lives, charities concerned with them attract substantial amounts of legacy income.

At the bottom of the heap are the small health charities and patient support groups (PSGs) which do work just as necessary and often as excellent as that done by larger ones. Usually run by volunteers, sometimes assisted by tiny teams of paid staff, they provide information for patients and carers, run support groups and helplines, and raise funds for research, albeit usually on a very modest scale. But their income streams are fragile. Their memberships (and therefore their subscription incomes), tend to be small.

There is fierce competition for grants from charitable trusts and the National Lottery; applications must be well written, coherent, convincing and persuasive, and many small charities simply do not have the resources to achieve that. Donations by businesses and individuals reflect public sympathy which, for ‘unglamorous’ conditions such as ataxia, facial disfigurement, narcolepsy and many skin diseases, is extremely limited. Setting up charity shops requires capital which small charities lack. With relatively few members and attracting little public sympathy, a small charity or PSG’s ability to organise or participate in fundraising events tends to be modest. Few people leave money to small, unglamorous charities in their wills. With little or no capital, such organisations have little or no investment income. And such is the competition for government grants that applying for them is rather like entering the lottery.

It is inevitable that In the sort of recession we are going through, membership of charities will fall and donations will be reduced. The largest charities will note this in their annual reports. Middle sized ones will wince and tighten their belts. The smallest ones will risk closure.

All this is why my heart sinks each time I see some thoroughly worthy body with the very best of intentions organising an annual charity day and selecting one of the bigger charities as the beneficiary, or nominating a similarly well-resourced organisation as their “charity of the year.” Of course the charity concerned will accept the money graciously, thank the donors warmly and add the funds to their already sizeable reserves. Consider, though, what that same sum could mean to one of the smaller charities or PSGs, which could put it to immediate and worthwhile use.

That is why I am so delighted to see the BMA adopting Changing Faces as its charity of the year. With clear vision and through sheer hard work, Changing Faces has become a stable and highly effective charity but, with an annual turnover of just over £1m, it is still classified as “small”, and we may be certain that any money donated to it will be put to very good use.

For anyone interested in identifying comparable charities and PSGs, many of them are members of National Voices the umbrella group for national voluntary organizations representing users of health and social care.

Peter Lapsley is patient editor of the BMJ and a lay member of the BMJ’s Ethics Committee. He was previously chief executive of the Skin Care Campaign, a Trustee of the Long-Term Conditions Alliance (now National Voices) – a Trustee of the DPP (Developing Patient Partnerships) and member of the Royal College of Physicians Patient & Carer Network.